Nebraska, Missouri and Virginia Benefit summary language updates effective May 1

April 2025

We’re updating the benefit summary for Nebraska, Missouri and Virginia to provide clarification on medically necessary services and materials. Benefit coverage will remain unchanged.

Reason for the updates

The purpose of these modifications is to clarify what is medically necessary and eliminate the need for code confirmations. Currently, providers must obtain a confirmation number for the services below, but with this change, providers will no longer have to request confirmations for these services.

We’ll perform these reviews throughout the claims process, and a valid medical diagnosis is required for payment of any claims that are filed. Additionally, these improvements will reduce the load on providers and improve patient access to care. The standards for diagnostic codes will be included in all medical procedure policies and will be available on our on our Provider Reference Guideopen_in_new page starting May 1, 2025.

You can still appeal claims and request clinical review of any contested claims. Our Peer Review Committee will review these requests to determine if they meet the requirements for medical necessity guidelines. 

The procedures and states being updated effective May 1, 2025, include the following.

Nebraska

Missouri

Virginia